Who decides the makings of a modern family?

Every few weeks, physicians at a Toronto fertility clinic provide treatment to help a transsexual man who used to be a woman get pregnant, taking advantage of still-intact wombs — and essentially making the patient both father and mother to his future child.

The service is one the Create Fertility Centre is happy to provide to couples it believes are well capable of being loving parents, despite their unconventional path to forming a family.

“People kind of have this misunderstanding about their situation; if they have organs from one or the other sex they were born with, it’s really no different than any of the other treatments we do,” said Dr. Cliff Librach, Create’s director. “Canada doesn’t have any law against having sex and having a baby. Why would we, if they needed help for some medical reason, stop them from getting help having children?”

Other physicians, however, are not so sure about this remarkable interplay of social change and medical technology, worrying that some transgendered people may still be susceptible to the psychological tumult that led them to have sex-change surgery, potentially putting their kids at risk.

The debate underscores a prickly issue facing Canada’s booming fertility industry. As a growing number and increasingly broad range of Canadians seek out their services, should the organizations act as gatekeepers and decide, essentially, who can become a parent? If so, what determines someone’s fitness to have progeny with the aid of reproductive technology?

Psychologists and doctors are grappling with how to handle clients who might be advanced in age, disabled, seriously ill, have spouses who appear less than enthused about having children — or may simply be of borderline intelligence or illiterate.

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Fertility professionals are divided on whether they should emphasize the interests of tomorrow’s children when assessing today’s patients — or focus on helping clients create families, avoiding personal value judgments on their capacity to raise the resulting offspring.

“People have babies [naturally] every day and nobody’s screening them,” said Donna Jacobs, a psychologist who counsels patients for a handful of Ontario fertility clinics. “Who is anybody to be the gatekeeper? There are people with bipolar [disorder] who have children, there are people with borderline personality disorder, people who are psychopaths. … Our role is to try and help people.”

Complicating the issue is that services like IVF, artificial insemination and surrogacy, once the domain chiefly of heterosexual couples with fertility problems, are now being offered increasingly to those whose barriers to parenthood are more social than medical, including same-sex couples, single women and even single men.

There seems to be little debate and considerable evidence that gay and lesbian parents do as fine a job as any at raising children, yet doctors, psychologists and lawyers say many scenarios they face are less clear cut.

When a woman from northern Quebec showed up at the McGill University fertility-treatment centre recently to start the process of provincially funded in-vitro fertilization, staff were shocked to see her black-and-blue face. The explanation was even more distressing: the would-be mother had been arrested for drunk-and-disorderly conduct and jailed overnight.

The woman failed to follow up on her initial visit, so the clinic did not have to pass judgment on her case, said Dr. William Buckett, a physician at the clinic. Which may have been a good thing, as Canada lacks any legal guidelines on handling such situations, making it a bit of a “Wild West,” said Dr. Buckett. He contrasts the environment here to that in his native U.K., where government-funded fertility specialists usually consult with family physicians before deciding whether a new patient would make a suitable parent.

“We live in a continent where individual rights seem very important: ‘It’s my right to have this, it’s my right to do this if I can pay for it.’ or whatever,” Dr. Buckett said. “Compared to many European countries, we have lost sight of the rights of the as-yet unborn child.”

A new wrinkle has been added by Quebec’s decision to fund in-vitro fertilization under medicare, in exchange for fewer embryos being inserted in women per treatment, a measure that has cut the rate of problematic multiple births. With the cost barrier for IVF gone, the number of patients has more than doubled, and the mix of individuals has broadened, too, encompassing some who have borderline IQs or are illiterate, noted Dr. Buckett.

He also notes the services are provided routinely to single women and single men who want to have children, or use surrogates, when some evidence points to poorer outcomes on average for children raised in single-parent families. He argues for a careful assessment of anyone whose parenting capacity might be in question, whether because of serious physical or mental illness, disability or some other factor.

“Anybody can go out and have sex and get pregnant,” he said. “But we are making somebody get pregnant who wouldn’t otherwise get pregnant, so we do have an additional responsibility. … I think as physicians, as anybody in medicine, we should make sure that anything we do does not cause any harm.”

But trying to judge who will make a good parent is fraught with peril, said Sherry Levitan, a Toronto lawyer who specializes in fertility cases. And Dr. Librach argues that people ready to invest their resources and bear what are often the difficulties and frustrations of fertility treatment have likely given the subject of parenthood considerable thought, and are more apt than most parents to value the resulting children.

“Frankly, children who are members of families in which they are wanted, loved, and supported are likely to thrive, irrespective of whether they have one, two or even multiple parents,” said Judith Daniluk, a psychology professor at the University of British Columbia and former fertility counsellor.

Even as she tries not to be a roadblock to treatment, though, Ms. Jacobs admits to being concerned about some of the situations she encounters as a counsellor.

There are, for instance, women who want IVF or other procedures but whose husbands, if they can be dragged to the counselling session, seem less than enthralled by the prospect. Others seek out fertility treatment shortly after losing another child and are deep in mourning, perhaps not the ideal emotional state in which to raise a baby.

Surrogacy arrangements can raise other issues. Ms. Jacobs has questioned using surrogate mothers who have experienced post-partum depression repeatedly after previous pregnancies. She also worries about the potential of coercion when a couple asks a nanny, or even an employee at the office, to be a surrogate.

She sometimes recommends clinics at least pause before proceeding with certain patients, but admits that they don’t always take the advice.

Gatekeeping practices differ from centre to centre, said Ms. Levitan, the lawyer.

Some clinics, while not openly admitting to it, quietly refuse to treat gay male couples or single men, or put tight restrictions on the age of patients. Others have no age limits, and generally take a “come one, come all” approach, she said. Noting that her own father was 51 when she was born — and a great parent — Ms. Levitan suggested it is dangerous to screen for parenting capacity.

“Someone could look at me and say ‘She works too many hours, she’s not a fit parent, she shouldn’t have a child.’ Where does it stop, where do you draw the line?” she asked. “Do you start instituting intelligence tests? What about a parent who travels for work? There are just so many arguments you could put forward for what is a good parent and isn’t a good parent.”

The focus by many clinics on the would-be parents rather than the eventual offspring, though, contrasts to the approach taken by adoption agencies, which carefully screen potential parents, argues Diane Allen, head of the support group Infertility Network and a frequent critic of the industry.

“What responsibility do they have to the family that will be created? It’s not being talked about.”

The debate is unfolding against the backdrop of a fast-changing industry.

In the 1980s, 95% of Ms. Daniluk’s Vancouver clients were heterosexual couples. By 2006, about a third of those who used donated sperm were lesbian women and a third single women, she said. Ms. Epstein estimates that as many as 25% of the clients at some clinics are lesbian, gay, bisexual or transsexual people.

A study by the Create clinic showed that it helped just two gay male couples have children with a surrogate between 2003 and 2006; from 2007 to last year, it served 27 gay couples — a 15-fold increase — and four single men.

And it now provides treatment to transsexual people about once a month, said Dr. Librach. Those who have transitioned from women to men can often get pregnant, so long as they temporarily stop taking male hormones. If the sexual reassignment surgery involved attaching a prosthetic penis, delivery of the baby has to be done by Caesarian section, he said. Transsexuals who have shifted from male to female are often still able to produce sperm, which can be used in fertility treatments.

In an article for the Infertility Awareness Association of Canada, Dr. Buckett pointed to evidence that men who have transitioned to women can have lingering psychological problems even after reassignment surgery, and suggested barring treatment for such clients. He softened his stance in an interview, however, saying each case should be judged on its merits.

Ms. Jacobs said she believes there are no grounds for discriminating against transsexuals, but said their background does raise “huge” parenting issues, and recommends to such patients that they clearly explain their origins when the children are old enough to understand.

A 2010 journal paper from the University of Illinois College of Medicine concluded there is no evidence that having transsexual parents triggers any harm in children that would disqualify them from assisted-reproduction services.

For Rachel Epstein of Toronto’s LGBTQ (lesbian, gay, bisexual, trans and queer) Parenting Network, resistance to transsexual people getting fertility treatment is just a replay of the unjustified prejudice lesbian and gay couples faced at most clinics a decade ago, and still encounter at some today.

“We get impatient with the arguments, and they’re very hurtful arguments. Can you imagine opening up the paper and reading an article about whether you were entitled to be a parent?” she said. “We very seldom wake up pregnant … so we are very reliant on reproductive technologies. We want to make sure we have fair and equitable access.”